Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction.

Background: Enhanced recovery after surgery (ERAS) protocols have been associated with hypotensive episodes after autologous breast reconstruction. Gabapentin (Gaba), a nonopioid analgesic used in ERAS, has been shown to attenuate postoperative hemodynamic responses. This study assesses ERAS's impact, with and without Gaba, on postoperative hypotension after microvascular breast reconstruction. Methods: Three cohorts were studied: traditional pathway, ERAS + Gaba, and ERAS no-Gaba. We evaluated length of stay, inpatient narcotic use [morphine milligram equivalents (MME)], mean systolic blood pressure, hypotension incidence, and complications. The traditional cohort was retrospectively reviewed, whereas the ERAS groups were enrolled prospectively after the initiation of the protocol in April 2019 (inclusive of Gaba until October 2022). Results: In total, 441 patients were analyzed. The three cohorts, in the order mentioned above, were similar in age and bilateral reconstruction rates (57% versus 61% versus 60%). The ERAS cohorts, both with and without Gaba, had shorter stays (P < 0.01). Inpatient MME was significantly less in the ERAS + Gaba cohort than the traditional or ERAS no-Gaba cohorts (medians: 112 versus 178 versus 158 MME, P < 0.01). ERAS + Gaba significantly increased postoperative hypotensive events on postoperative day (POD) 1 and 2, with notable reduction after Gaba removal (P < 0.05). Across PODs 0-2, mean systolic blood pressure was highest in the traditional cohort, followed by ERAS no-Gaba, then the ERAS + Gaba cohort (P < 0.05). Complication rates were similar across all cohorts. Conclusions: Postmicrovascular breast reconstruction, ERAS + Gaba reduced overall inpatient narcotic usage, but increased hypotension incidence. Gaba removal from the ERAS protocol reduced postoperative hypotension incidence while maintaining similar stay lengths and complication rates.

Reversal in Centers for Medicare & Medicaid Services Reimbursement for Deep Inferior Epigastric Perforator Flap Reconstruction-Empowering Plastic Surgeons in Sustaining Microsurgical Accessibility.

ABSTRACT: This Editorial discusses the recent overturning of a proposed Centers for Medicare & Medicaid Services policy that reduced reimbursement for deep inferior epigastric perforator flap breast reconstruction. The authors highlight the importance of advocacy efforts in sustaining access to complex microsurgical procedures, even those under investigation such as breast reinnervation and lymphatic reconstruction.

Same-Day Discharge for Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study.

BACKGROUND: Patients undergoing immediate breast reconstruction with tissue expanders are frequently admitted after surgery for monitoring and pain control, which introduces additional costs and risks of nosocomial infection. Same-day discharge could conserve resources, mitigate risk, and return patients home for faster recovery. The authors used large data sets to investigate the safety of same-day discharge after mastectomy with immediate postoperative expander placement. METHODS: A retrospective review was performed of patients in the National Surgical Quality Improvement Program database who underwent breast reconstruction using tissue expanders between 2005 and 2019. Patients were grouped based on date of discharge. Demographic information, medical comorbidities, and outcomes were recorded. Statistical analysis was performed to determine efficacy of same-day discharge and identify factors that predict safety. RESULTS: Of the 14,387 included patients, 10% were discharged the same day, 70% on postoperative day 1, and 20% later than postoperative day 1. The most common complications were infection, reoperation, and readmission, which trended upward with length of stay (6.4% versus 9.3% versus 16.8%), but were statistically equivalent between same-day and next-day discharge. The complication rate for later-day discharge was statistically higher. Patients discharged later had significantly more comorbidities than same or next-day discharge counterparts. Predictors of complications included hypertension, smoking, diabetes, and obesity. CONCLUSIONS: Patients undergoing mastectomy with immediate tissue expander reconstruction are usually admitted overnight. However, same-day discharge was demonstrated to have an equivalent risk of perioperative complications as next-day discharge. For the otherwise healthy patient, going home the day of surgery is a safe and cost-effective option, although the decision should be made based on the individual patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction.

Background: Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center. Methods: The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls. Results: The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant. Conclusion: Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction.

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes. Methods: All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed. Results: In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model. Conclusions: Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

Postsurgical Outcomes with Meshes for Two-stage Prosthetic Breast Reconstruction in 20,817 Patients.

Use of acellular dermal matrices (ADMs) for tissue expander breast reconstruction remains controversial with an uncertain safety and efficacy profile. This study analyzes the rates and factors for reoperation and postoperative infection in patients who underwent tissue expander breast reconstruction with and without ADM. Methods: Patients who underwent breast reconstruction with and without ADM were identified from the National Surgical Quality Improvement Program database utilizing CPT codes. Covariates included patient demographics, preoperative comorbidities, and operative characteristics, while outcomes of interest were postoperative infection and reoperation. Univariate and multivariate analyses were performed to identify predictors of adverse outcomes. Results: There were 8334 patients in the ADM cohort and 12,451 patients who underwent tissue expander breast reconstruction without ADM. There were significantly fewer reoperations in the non-ADM cohort (5.4%) compared to the ADM cohort (7.7%) (P < 0.0001), with infection and hematoma as the most common etiologies in both cohorts. Surgical infections were also more prevalent in the ADM cohort (4.7%) compared with the non-ADM cohort (3.6%) (P < 0.0001). Univariate and multivariate analysis of the tissue expander breast reconstruction cohort revealed race, obesity, hypertension, smoking status, albumin, and operative time as predictive for infection risk, while race, obesity, hypertension, smoking, albumin, operative time, and age were significant for reoperation. Conclusion: Our study of 20,817 patients revealed significantly higher risk of infection and reoperation in patients who underwent breast reconstruction utilizing ADM versus without ADM. Patients considering ADM for breast reconstruction should engage in discussion with their surgeon about complications, aesthetics, and cost.

Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: A National Surgical Quality Improvement Project-based study.

BACKGROUND: Post-mastectomy free-flap breast reconstruction is becoming increasingly common in the United States. However, predicting which patients may suffer complications remains challenging. We sought to apply the validated modified frailty index (mFI) to free-flap breast reconstruction in breast cancer patients and determine its utility in predicting negative outcomes. METHODS: We conducted a retrospective study using National Surgical Quality Improvement Project (NSQIP). All patients who had a CPT code of 19364, indicative of free tissue transfer for breast cancer reconstruction, were included. Data on preoperative characteristics and postoperative outcomes were collected. Patients were separated based on the number of mFI factors present into three categories: 0, 1, and > 2 factors. Preoperative demographics, clinical status, and other comorbidities were also studied. Negative outcomes were compared using multivariate logistic regression. RESULTS: 11,852 patients (mean age 50.9 ± 9.5) were found; 24.2% had complications, comparable to previous literature. mFI is predictive of all types of negative outcomes. 22.5% of all patients with 0 mFI, 27.7% of patients with 1 mFI and 34.2% of patients with at least two mFI had a negative outcome. The most common factors contributing to the mFI were history of hypertension (24.8%) and diabetes (6.1%). mFI was found to be an isolated risk factor for negative outcomes, along with steroid use, American Society of Anesthesiology (ASA) classification, body mass index, and immediate, and bilateral operations. CONCLUSIONS: This NSQIP-based study for patients undergoing free flap breast reconstruction shows that the mFI holds predictive value regarding negative outcomes. This provides more information to properly counsel patients before free flap breast reconstruction surgery.

Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance.

BACKGROUND: In the past decade, surgeons have increasingly advocated for a return to prepectoral breast reconstruction with claims that surgical mesh (including acellular dermal matrix) can reduce complication rates. However, numerous surgical and implant advancements have occurred in the decades since the initial prepectoral studies, and it is unclear whether mesh is solely responsible for the touted benefits. METHODS: The authors conducted a systematic review of all English language articles reporting original data for prepectoral implant-based breast reconstruction. Articles presenting duplicate data were excluded. Complications were recorded and calculated on a per-breast basis and separated as mesh-assisted, no-mesh prior to 2006, and no-mesh after 2006 (date of first silicone gel-filled breast implant approval). Capsular contracture comparisons were adjusted for duration of follow-up. RESULTS: A total of 58 articles were included encompassing 3120 patients from 1966 to 2019. The majority of the included studies were retrospective case series. Reported complication outcomes were variable, with no significant difference between groups in hematoma, infection, or explantation rates. Capsular contracture rates were higher in historical no-mesh cohorts, whereas seroma rates were higher in contemporary no-mesh cohorts. CONCLUSIONS: Limited data exist to understand the benefits of surgical mesh devices in prepectoral breast reconstruction. Level I studies with an appropriate control group are needed to better understand the specific role of mesh for these procedures. Existing data are inconclusive but suggest that prepectoral breast reconstruction can be safely performed without surgical mesh.

Re-exploration of vertical rectus abdominis myocutaneous flap for vaginal reconstruction: Case report and review of the literature.

The vertical rectus abdominis myocutaneous (VRAM) flap is a versatile and well-established reconstructive technique for many defects created as a result of colorectal and gynecologic extirpation. However, major re-operation in the pelvis following a VRAM flap reconstruction several months later is uncommon, and the safety and integrity of the VRAM flap in this setting has not been described. This case examines VRAM flap preservation during repeat exploratory laparotomy, and a unique view of the VRAM flap during interval exploration. We demonstrate an intact flap after lysis of adhesions with an audible Doppler signal, and maintenance of flap integrity in the postoperative period. This further substantiates its use as a durable rotational flap for perineal tissue defects.

Implant-based immediate breast reconstruction in the previously augmented patient.

BACKGROUND: Millions of women have undergone augmentation mammaplasty with implants and breast cancer continuing to be the most common non-cutaneous malignancy in female patients. Reconstructive surgeons will inevitably encounter breast cancer patients with prior augmentation. Implant-based techniques represent the most common form of breast reconstruction overall and remains a common option among those who were previously augmented. OBJECTIVE: The purpose of this study is to evaluate outcomes of implant-based reconstruction in previously augmented women. METHODS: A retrospective review from September 2004 to December 2009 was performed. 38 women (63 breasts) with a history of prior augmentation (PA) who underwent implant-based reconstruction were identified and compared to a non-prior augmented (NPA) control group (77 patients; 138 breasts). Normative data, augmentation details, reconstruction method, complication rates, and revision rates were evaluated. RESULTS: The total complication rate was significantly different between the two groups with 18 complications (28.6%) occurring in 9 PA breasts and 20 complications (14.5%) in 19 NPA breasts (p-value 0.037). When analyzed by specific complication subtypes, capsular contracture was the only complication that bordered significance between the two cohorts (p-value 0.057). Complication rates were otherwise similar regardless of augmentation or reconstruction type. CONCLUSION: Implant-based reconstruction is a safe option for previously augmented patients that is able to provide outcomes similar to non-augmented patients. Results are not affected by the location of previous implants or the implant-based reconstruction method. There may be a higher incidence of capsular contracture in the previously augmented patient that warrants further investigation and preoperative discussion.

Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions.

BACKGROUND: Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction. METHODS: Patients undergoing primary implant-based (n = 1038) or flap-based (n = 837) reconstructions from 2004 to 2012 at the University of California, Los Angeles, were evaluated. Postoperative pain was measured using the visual analogue scale, total narcotic use, and number of patient-controlled analgesia attempts. Narcotic dosage was standardized to morphine equivalents per kilogram. The authors modeled postoperative narcotic use, patient-controlled analgesia attempts, and visual analogue scale scores over time using spline graphs for comparison between the two reconstruction methods. RESULTS: Both total narcotic use and patient-controlled analgesia attempts were higher in the implant-based group throughout the immediate postoperative period. Implant-based reconstruction patients had significantly higher visual analogue scale scores (p < 0.0001) and total narcotic use (p < 0.0001) through postoperative day 3 compared with autologous tissue-based reconstruction patients. When controlling for reconstruction method, bilateral procedures were more painful (visual analogue scale score and patient-controlled analgesia attempts, both p < 0.001). When controlling for laterality, unilateral implant-based and autologous reconstructions had comparable visual analogue scale scores (p = 0.38) and patient-controlled analgesia attempts. However, unilateral implant-based procedures required more narcotic use than unilateral autologous tissue-based procedures (p = 0.0012). CONCLUSION: Although commonly perceived as a less distressing operation, implant-based breast reconstruction may be more painful during the immediate postoperative hospitalization than abdominally based free tissue transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction.

BACKGROUND: The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. METHODS: All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. RESULTS: A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. CONCLUSIONS: Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

CASE REPORT Treatment of a Lower Extremity Lymphocele With Intraoperative Lymphatic Mapping.

OBJECTIVE: Lower extremity lymphoceles secondary to saphenous vein grafting are exceptionally rare and there is only 1 previously reported case in the English literature. Data on treatment of lower extremity lymphoceles are limited and based on studies of groin lymphoceles. We discuss operative resection with selective ligation of feeding lymphatic vessels as a treatment option of lower extremity lymphoceles. METHODS: A 64-year-old man who had undergone coronary artery bypass grafting 6 years prior presented with a left lower extremity mass at the site where his saphenous vein had been harvested. Examination demonstrated a 12-cm, mobile, nonpulsatile mass at his medial left calf. The findings of magnetic resonance imaging were consistent with a lymphocele. RESULTS: Intraoperative injection of isosulfan blue dye was used to identify feeding lymphatic vessels and the lymphocele cavity was excised. Leg drains were discontinued after 3 days, and the patient was discharged home after 6 days. CONCLUSION: Operative resection with isosulfan blue dye lymphatic mapping and selective ligation of lymphatic vessels is a viable treatment of lower extremity lymphoceles.

Salvage rates of compromised free flap breast reconstruction after recurrent thrombosis.

BACKGROUND: Microvascular complications after free flap breast reconstruction are devastating problems that increase patient morbidity and potentially lead to flap loss. Yet, there is a dearth of literature about rates of free flap salvage after recurrent vascular thromboses. METHODS: A retrospective review of all patients undergoing microvascular breast reconstruction at UCLA Medical Center from January 1991 to June 2010 was conducted. The incidence of microvascular thrombosis was evaluated and rates of flap salvage and complications were specifically analyzed after a single microvascular revision (Single Event), 2 or more revisions (Multiple Event), and delayed presentation (>2 days) with attempted salvage (Delayed Event). RESULTS: During the study period, 2094 free flap breast reconstructions were evaluated. Of these, 75 (3.6%) flaps suffered a microvascular complication and 16 (0.76%) flaps were lost. The overall salvage rate was 78.7% (59/75) with the highest salvage rate of 95.9% (47/49) for Single Events. Multiple Events had a salvage rate of 53.3% (8/15), whereas Delayed Events had a salvage rate of 27.3% (3/11). The salvage rate decreased with repeated microvascular events (P < 0.01). In the Multiple Event group, vascular conversion (alternate recipient vessel) correlated with improved flap salvage (87.5%), whereas the lack thereof was associated with flap loss (P < 0.001). CONCLUSIONS: The salvage rate of free flap breast reconstruction diminishes dramatically with recurrent microvascular complications, but can be improved with vascular conversion. The salvage rate in cases of delayed presentation is even worse confirming the need for vigilant postoperative monitoring and aggressive intervention in the setting of flap compromise.

Chest wall reconstruction for sternal dehiscence after open heart surgery.

BACKGROUND: Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined. MATERIALS AND METHODS: A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay. RESULTS: Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay. CONCLUSIONS: Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.

Effects of radiation therapy for breast cancer based on type of free flap reconstruction.

BACKGROUND: Adjuvant radiation therapy for locally advanced breast cancer decreases local recurrence and improves survival. Immediate autologous breast reconstruction before postmastectomy irradiation is highly controversial. However, it is presently unknown whether there exist differences in the durability of various autologous flaps (myocutaneous or fasciocutaneous) to the effects of radiation. METHODS: All patients who underwent autologous breast reconstruction at the authors' institution between July of 2002 and July of 2005 were evaluated retrospectively. Patients who did not complete all stages of their reconstruction at the authors' institution were excluded. Free flap types were analyzed based on postoperative radiation exposure versus no radiation exposure. The authors also analyzed patients who underwent reconstruction in a delayed fashion with prior radiation exposure and assessed overall outcomes for early and late complications and secondary breast procedures. RESULTS: Three hundred sixty-three of 446 flaps (81 percent) were included in the analysis, with the three most common flaps being the free transverse rectus abdominis myocutaneous (TRAM) flap (7.4 percent), the muscle-sparing free TRAM flap (44 percent), and the deep inferior epigastric perforator flap (41 percent). There were no significant differences in early or late complications among the different flap types or radiation categories. Flaps with prior radiation exposure were associated with higher percentages of contralateral symmetry procedures, whereas flaps with postoperative radiation exposure had a lower incidence of ipsilateral revisions. CONCLUSIONS: Autologous breast reconstruction can be performed safely regardless of preoperative or postoperative radiation therapy. There are no significant differences in complication rates or number of revisions based on the type of free flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of implant-based immediate breast reconstruction with and without acellular dermal matrix.

BACKGROUND: Acellular dermal matrix is frequently used in implant-based breast reconstruction to cover the inferior aspect of the breast pocket. Its performance profile remains equivocal. The authors studied whether adding it in implant-based immediate breast reconstruction improved outcomes when compared with non-acellular dermal matrix reconstruction. METHODS: Patients undergoing implant-based immediate breast reconstruction at a single academic medical center were evaluated. Aesthetic outcomes and postoperative complications were assessed and direct comparisons were made between acellular dermal matrix and non-acellular dermal matrix cohorts. RESULTS: A total of 203 patients underwent 337 immediate expander-based breast reconstructions [with acellular dermal matrix, n=208 (61.7 percent); without, n=129 (38.3 percent)]. Patient characteristics, including age at time of reconstruction (mean, 49±11 versus 47±10 years) and body mass index (mean, 23±5 versus 23±3 kg/m) were similar between groups (p>0.05). Complications occurred in one-third of patients (33.5 percent). In univariate analyses, acellular dermal matrix use had fewer overall complications (odds ratio, 0.61; 95 percent CI, 0.38 to 0.97). The incidences of seroma/hematoma (p=0.59), infection (p=0.31), and wound complications (p=0.26) did not differ. Aesthetic outcomes were higher in the acellular dermal matrix group. In multivariate logistic regression, acellular dermal matrix use was associated with less capsular contracture (odds ratio, 0.18; 95 percent CI, 0.08 to 0.43) and mechanical shift (odds ratio, 0.23; 95 percent CI, 0.06 to 0.78). CONCLUSIONS: Optimizing the inframammary fold with acellular dermal matrix creates a superior aesthetic result. Its use appears safe and is associated with less capsular contracture and mechanical shift and improvement in the inframammary fold appearance, without increasing postoperative complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Vascular complications and microvascular free flap salvage: the role of thrombolytic agents.

BACKGROUND: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. METHODS: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. RESULTS: Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). CONCLUSIONS: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.